OASI Care Bundle RCM and RCOG comment

By Louise Silverton on 24 May 2019 OASI - Obstetric anal sphincter injuries

In 2014 the RCM and the RCOG decided that something needed to be done to address the increasing rates of OASI (obstetric anal sphincter injury). OASI has an enormous negative impact on the lives of those affected. Following a round table discussion about the global evidence it was decided to develop a care bundle to reduce incidence.

A care bundle is a series of evidence based interventions which, if performed together, magnify the effects of following the, individually. Only those interventions which can be performed consistently were included. We were advised at the time that not all units were able to provide warm compresses at the correct temperature and for that reason this was not included.

The care bundle was presented to a group of influential RCM members committed to midwifery practice around labour and birth. Subsequently the care bundle was amended and met with their agreement.

The elements of the care bundle are:

1. educating women about OASI in the antenatal period including the understanding of their individual risk factors

2. performing an episiotomy when indicated. (This is especially pertinent for instrumental births)

3. manual perineal protection during birth of the head and shoulders if the birth position permits it, and

4. per rectum examination after birth to ensure that there is no hidden damage.

The care bundle was piloted in two units with good results. After this application was made to the Health Foundation as part of their scaling up programme. Using a stepped wedge design the care bundle was implemented in 16 maternity units across Great Britain. The purpose of the study was one of quality improvement. The outcome measures included reduction in OASI rates, acceptability of the care bundle to women and also to midwives and obstetricians.

Results presented last November showed the care bundle was acceptable to women midwives and obstetricians and, that it significantly reduced overall OASI rates from 3.3% to 3.0%. There was no increase in overall episiotomy or Caesarean section rates. The detailed results are currently being submitted for publication.

The study team are currently planning a further project (subject to funding) to explore how best to implement a safe bundle of this kind. The participating units who attended a study day earlier this week have shown commitment and courage in challenging practice and putting women first. They spoke of continuing improvements to care and the need to reinforce the messages around the acre bundle.

In response to numerous requests for resources used during the programme are available here. The RCM and RCOG are also working with the MASIC foundation to support women who have experienced OASI.